Migraine remission with ketamine – 20 years constant pain

03/29/2016 — Nancy Sajben MD

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Ketamine

Migraine Case Report

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A 65 year old man reported 20 years of constant daily migraine without aura, with nausea, photophonophobia, triggered by barometric changes. Zomig or Imitrex would dull the pain a bit but it was never gone. Oxycontin 50 mg daily 6 months of every year dulled the pain but the nausea of migraine still persisted. He would taper off the opioid every 6 months, enduring weeks of withdrawal symptoms. He had been seen by some of the foremost migraine specialists in the country, and saw other neurologists before seeing me a few months ago.

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We elected to trial ketamine in a nasal spray – it can also be given under the tongue.

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I had never been convinced ketamine would work for migraine and often refer migraineurs to migraine specialists who offer Botox. However, I was encouraged by the report of the UCLA migraine expert, Alan Rapoport, MD, President of the International Headache Society, that injections of ketamine given repeatedly IM in the office, help status migrainosis.

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The issue encountered with ketamine in treating this patient was side effects. Therefore, I asked him to lower the dose to a one that produces no side effects, repeat that lower dose 3 times per day for 2 or 3 days. That generally allows the body to develop tolerance to side effects so thereafter higher doses can be tested.

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Ketamine has no effect on pain, none whatsoever, until you reach your dose, that is different in everyone. The dose is idiosyncratic, it differs in everyone

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For pain, ketamine at an effective dose relieves pain in 10 to 15 minutes.

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He never reached an effective dose because of side effects. Instead, after a few weeks on a dose he could tolerate without side effects, migraine went into complete remission. Complete remission for months. For at least three months, he’s had no migraine. This is the first time in 20 years he has been headache free. Never free of migraine for even one day.

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Ketamine is a powerful glial modulator. It reduces pro-inflammatory cytokines in the CNS. We tried adding another glial modulator but in two or three days he developed a migraine, stopped the drug, and after another one or two migraines more, he has been migraine free for a few weeks since then.

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For now, he remains on ketamine three times a day and is now trying twice daily dosing.

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As always, in any patient on medication that could have potential organ toxicity or lead to addiction, I monitor blood and urine regularly.

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This is unique.

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For about 15 years, I have treated patients with ketamine daily for chronic pain, those who have failed all prior medications, procedures, pumps and spinal cord stimulators. But we have always stopped if failing to achieve relief. I have no one who continued sub-therapeutic doses for 4 weeks or more despite no effect. None. This man did and now has sustained complete remission with no side effects.

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Less is more.

Is that true for other forms of chronic pain?

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It is important not to lock onto one dose if less will work. If, as research shows, ketamine lowers inflammatory cytokines in brain and cord, then over time, we may need less to maintain effect. At this time, we are very slowly decreasing daily frequency, very slowly, over months, to avoid triggering recurrence.

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This site is not for email.

If any questions, please schedule an appointment with my office.

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Public Warning:

Ketamine is a controlled substance.

Administered improperly, or without the guidance of a qualified doctor,

Ketamine may cause injury or death.

No attempt should be made to use Ketamine

in the absence of counsel from a qualified doctor.

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“Off label” means ketamine is FDA approved for another purpose, decades ago it was approved for anesthesia. In qualified hands, ketamine is one of the safest medications we have in our formulary.